We Don't Need the UN to Regulate Baby Formula
Last month, the New York Times reported that the Trump administration had been pressuring other countries at the UN to oppose a resolution supporting more widespread use of breastfeeding. This was, in turn, portrayed by much of the media as the Trump administration taking a stance "against breastfeeding," which is today almost universally regarded as a superior form of nutrition for infants, when compared to baby formula.
The New Republic, for instance, declares "The Trump administration takes a bold stance against mother’s milk." A medical journalism site even claims "In Shocking Opposition, Trump Administration Denies Decades of Breastfeeding Research."
It's hard to see how opposition to the UN resolution in question translates into opposition to the fact that many scientists currently think breastfeeding is a good thing.
It's important to note that the UN resolution wasn't simply a bland declaration that breastfeeding is good. It also called for government regulation of marketing of baby formula. In other words, it's entirely plausible that, as the administration claims, it is opposing government regulation and restrictions on formula manufacturers — and therefore opposes restrictions on greater access to information about formula by people who want to use it.
Moreover, calls for greater government regulation of the formula industry have become commonplace in UN resolutions since 1974 when the Twenty-Seventh World Health Assembly, urged "Member countries to review sales promotion activities on baby foods to introduce appropriate remedial measures, including advertisement codes and legislation where necessary," Since then, as noted by Silvia Diez and Antonio Barros in "The History of Infant Nutrition," several UN agencies "took action to prohibit advertising of baby milk, bottles, teats and pacifiers."
This is the political context into which the Trump administration waded when it took a stance against the latest international declaration of support for additional government controls on various substances and tools devoted to the use of baby formula.
A Brief History of Baby Formula in America
As The New York Times reported in a follow-up story in July, "medical experts" are criticizing the Trump Administration for its stance on the resolution. As with the media in general, the medical industry is acting as if the only content of the resolution is a scientific question of the nutritional value of breastfeeding. But the true question at hand is beyond the expertise of the medical profession. Namely, it's a political question of whether the advertising of baby formula ought to be coercively regulated or prohibited by governments.
Strictly speaking, this is a matter for researchers who debate whether or not consumers are really slaves to the messages they receive from advertisers. There is not, in fact, any conclusive evidence that people simply do what advertisers tell them to do. If that were true, Hillary Clinton, who vastly out-spent Donald Trump in campaign spending, would have won the 2016 election in a landslide. Nevertheless, the UN's pre-occupation with forcibly preventing the marketing of baby formula is premised on this idea.
There is do denying the fact, however, that aggressive marketing of baby formula coincided with a significant rise in the use of baby formula in the mid-twentieth century.
For example, in 1940, 72 percent of mothers initiated breastfeeding with their babies. By 1968, this had dropped to a nadir of 24 percent. After 1972, though, breastfeeding once against began to gain ground, and by 2009, 72 percent of American mothers were once again avoiding baby formula.
We see a similar trend with mothers breastfeeding at least six months. In 1940, 42 percent of mothers were breastfeeding for at least six months, but this fell to 6.4 percent in 1970. By 2009, 35 percent were breastfeeding six months or more.
Source: "Breastfeeding in the United States: Economic Analyses of Trends and Policies" by Lindsay Gartman Baker
What are the reasons for these large fluctuations over time?
While many scholars repeatedly mention the marketing of formula as an issue, a broader view of the history of formula makes it more difficult to proffer mere marketing as the driving factor.
After all, it's not a coincidence that formula feeding gained popularity during the 1940s and 1950s, just as food processing technology and hygiene technology were advancing together to allow for use of baby formula in way that did not lead to high mortality rates. High mortality, of course, had been the case for babies whose mothers had been unable to breastfeed in earlier decades and centuries.
As Emily Stevens, et al note in "A History of Infant Feeding,"
In the early 19th century, the use of dirty feeding devices, combined with the lack of proper milk storage and sterilization, led to the death of one third of all artificially fed infants during their first year of life ... The use of artificial formula [into the late nineteenth century] was associated with many summertime infant deaths due to the spoilage of milk left in bottles.
This didn't stop manufacturers of formula from marketing their products heavily throughout the nineteenth century, though. Baby formula producers advertised heavily in a variety of periodicals from the 1860s through the 1920s. The advertising, though, did not lead to widespread adoption of formula use. This was in part because formula was known to be so perilous for babies. It remained inconvenient and expensive, and many women who did use formula used homemade versions made from condensed milk and similar items.
Widespread adoption of formula only became widespread with the proliferation of refrigeration in the 1920s and 30s which itself followed the expansion of easy access to clean water through indoor plumbing.
Also, by the mid-twentieth century, mothers understood that formula could finally be produced with refrigerated milk and with clean water in such a way that had not been widely available before. Thus, for many women, it became perfectly rational to attempt to use formula while their justifiably more cautious mothers and grandmothers had eschewed the use of formula.
On top of this, the advent of "scientific motherhood" had begun to dominate the national conversation over mothering. Scientific motherhood was a Progressive Era concept in which women were told that scientific expertise could help them be more effective, safe, and prudent mothers. This was offered in opposition to earlier notions of "moral motherhood" promoted by the Victorians in earlier decades.
Jessica Martucci writes in Back to the Breast:
[T]he decline of the Victorian era's moral mother paralleled the rise of scientific motherhood and bottle feeding. In return the ideology of scientific motherhood promised to elevate the maternal role to that of a respected technical occupation."
Deference to scientific and medical experts was a central component of the ideology, and this would be key as many medical personnel increasingly promoted the use of baby formula.
This decline in resistance from the medical community becomes easier to understand when we consider that for the first time, formula looked to many to be almost as good as breast milk. But, while mortality rates of bottle-fed babies had been cut substantially by the 1940s, it was still recognized by researchers that breastfeeding remained superior in terms of health outcomes. Indeed, one of the most widely read "guides" to mothering, a 100-page pamphlet called Infant Care unambiguously asserted that breastfeeding was superior. Printed by the federal government beginning in 1913, 59 million copies had been distributed in various updated editions until the 1970s.
Nevertheless, medical practitioners themselves often became unenthusiastic about promoting breastfeeding.
For example, author Letitia Sage, writing in a nursing journal in 1947, recounted her own experience in a hospital ward immediately after giving birth. Martucci sums up Sage's account:
"Try nursing her for five minutes and then give her this," said the nurse, putting a bottle filled with two ounces of formula within reach." The nurse left and Sage set to work, only to find that her daughter was distinctly apathetic" and that she, herself, was "terrified" throughout the experience. "After a brief and unsatisfactory struggle for all concerned," she wrote, "I reached for the bottle." Her hungry daughter drained it. This process continued for days while Sage was in the hospital each time she tried to breastfeed, her daughter's fits of howling would bring the nurses running with reassuring smiles and bottles in hand. As one of her nurses explained after a particularly tense session, "Cheer up — she won't starve even if you can't nurse her!"
The reader is meant to take this experience as relatively common during the period.
The Relationship Between Formula Manufacturers and the Medical Industry
Although the medical profession is today attempting to make itself out to be the perennial white knight on breastfeeding issues, the fact is that it was the medical profession that became quite comfortable with formula feeding — and with the formula industry itself — at mid-century. This relationship was further enhanced to assert the importance of medical personnel themselves in the decision-making process around infant nutrition. Stevens, et al write:
As formulas evolved and research supported their efficacy, manufacturers began to advertise directly to physicians. By 1929, the American Medical Association (AMA) formed the Committee on Foods to approve the safety and quality of formula composition, forcing many infant food companies to seek AMA approval or the organization's “Seal of Acceptance.” Three years later, advertising became regulated so that manufacturers could not solicit information to nonmedical personnel, which facilitated a positive relationship between physicians and the formula companies.
These government regulations on advertisements were often supported by the medical industry, but not necessarily out of a concern for patients. By limiting access to information on formula, doctors were able to further extend their control over patients. "In Marketing Breastfeeding—Reversing Corporate Influence on Infant Feeding Practices" Deborah Kaplan and Kristina Graff write:
From the early twentieth century until the late 1980s, most formula companies abandoned direct-to-consumer advertising and used the medical community as their sole advertising vehicle. In lieu of directions on how to prepare the formula and recommended dosages, formula package instructions advised mothers to obtain formula feeding guidance at regular doctor visits — yielding a steady flow of income for physicians. Formula companies further engendered physicians’ goodwill by sponsoring scientific conferences and research on infant nutrition. Doctors retained their role as undisputed advisors on infant health and feeding while simultaneously providing product referrals for formula purchase and serving as an advertising source of unparalleled credibility.
In these situations, the key factor in promoting formula was not advertising to the impressionable masses. It was the medical professionals following the lead of the AMA and endorsing formula usage as "experts."
In spite of all of these efforts to promote formula, though, formula usage began to go into decline in the 1970s. Much of this was due to activist organizations like the La Leche League, and it also illustrates the limits of advertising's effects on behavior. Nearly 20 years after formula companies started losing ground in the US, in 1988, they began directly marketing their products to consumers — at least in the United States. It didn't reverse the trend. Usage of baby formula continued to decline. Breastfeeding initiation rates increased from 54 percent in 1988 to 73 percent in 2009. According to a separate survey by the Centers for Disease control,
The percentage of babies who start out breastfeeding increased from 73% among babies born in 2004 to 83% among babies born in 2014. Babies are also breastfeeding for longer; 55% of U.S. babies born in 2014 were being breastfed at 6 months, up from 42% in 2004.
It's likely that's a 75-year high.
So why does the idea persist that consumers are simply at the mercy of formula makers who market to them? The idea is nothing new, as is clear in the fact that Ludwig von Mises once felt the need to clarify in Human Action:
It is a widespread fallacy that skillful advertising can talk the consumers into buying everything that the advertiser wants them to buy. The consumer is, according to this legend, simply defenseless against "high-pressure" advertising. If this were true, success or failure in business would depend on the mode of advertising only. However, nobody believes that any kind of advertising would have succeeded in making the candle makers hold the field against the electric bulb, the horse drivers against the motorcars, the goose quill against the steel pen and later against the fountain pen. But whoever admits this implies that the quality of the commodity advertised is instrumental in bringing about the success of an advertising campaign.
In truth, advertising is nothing more than a producer providing information about its product — information the consumers often rejects. However, as was the case in the mid-twentieth-century United States — when ideological and material conditions combine to significantly change perceptions about the safety and a convenience of a product — demand for that product can change substantially.
Today, the developing world is going through many of the changes that the United States went through in the early decades of the twentieth century. Sanitation has improved and clean water is more readily available. As urbanization increases so does access to both refrigeration and formula products themselves. For the first time ever, many of these women have an actual choice when it comes to breastfeeding or formula feeding.
Naturally, it would be all to the good that private sector organizations, including medical professionals work to supply mothers with the information they need to make informed choices. The UN's current position, however, is that formula producers ought to be prevented — by government diktat — from presenting their products to consumers. This idea endures even though government regulators can never know ahead of time which women will actually need to use formula, and under what circumstances. These are choices only individuals can make armed with information specific to their individual cases. To intervene to control what information those mothers can access is nothing other than paternalism.